Peripheral Seeding of Mycotic Aneurysms from an Infected Aortic Stent Graft

Aortic stent graft infection is rare and there are no reported cases of seeded peripheral mycotic aneurysms complicating this condition. We describe the case of a 54 year old man who developed a late stent graft infection at three years, resulting in the peripheral seeding of three mycotic aneurysms with two incidents of rupture. He was successfully treated with extra-anatomic bypass of the aorta and both surgical and endovascular repair of his peripherally seeded mycotic aneurysms.     

Challenges in the Diagnosis of the Right Patient for Testosterone Replacement Therapy

Diagnosis of testosterone deficiency is important to identify patients who might benefit from testosterone replacement therapy. Unfortunately, the diagnosis of hypogonadism may be a challenge for many practicing physicians, including endocrinologists and urologists. Signs and symptoms, such as sexual dysfunction, change in body composition, lethargy, and mood changes, are nonspecific and the available questionnaires are generally not useful in clinical practice. The diagnosis of testosterone deficiency is ultimately based on measurement of serum testosterone levels. However, marked variations in the reference ranges of serum testosterone levels among laboratories pose a challenge for physicians when interpreting the results. In addition, initial laboratory assessments usually determine total testosterone levels. About 1–2% of total testosterone is free and a further 30–50% is bound with low affinity to albumin; only these two components are bioavailable to the target tissues. In general, assuming the normal reference range for serum total testosterone in adult men is 300–1000 ng/dl (10–35 nmol/l), levels of < 250 ng/dl (8.7 nmol/l) suggest the patient is likely to be hypogonadal, whereas levels of > 350 ng/dl (12.7 nmol/l) suggest the symptoms may not be due to androgen deficiency. Values between 250 to 350 ng/dl warrant a repeat morning serum testosterone determination with assessment of free or bioavailable testosterone. In men with symptoms suggestive of androgen deficiency and borderline serum testosterone levels, where there are no contraindications to androgen therapy, a short therapeutic trial of testosterone may be justified.     

Prosthetic valve endocarditis due to candida albicans treated successfully with medical treatment alone

Prosthetic valve endocarditis (PVE) caused by Candida species is associated with high morbidity and mortality. A combination of surgical resection and antifungal drug therapy is the golden standard for treatment, yet surgical intervention is not possible in all cases of Candida PVE. We report a case of PVE due to Candida albicans cured by medical treatment alone. This case suggests that, in some instances, Candida PVE can be managed medically with antifungal therapy. Such a conservative approach should be applied with caution and necessitates very close follow-up on a long-term basis.     

Perioperative Complications of the Agility Total Ankle Replacement in 50 Initial, Consecutive Cases

Although functional and clinical outcomes after total ankle arthroplasty have been promising, a steep learning curve has been recognized. In addition, the performance of concomitant hindfoot realignment procedures is controversial. The purpose of this study was to report on a single surgeon's experience with the first 50 total ankle arthroplasty procedures. We wanted to define the characteristics of the learning curve and whether the rate of complications was increased in patients who required complex reconstruction for preexistent foot and ankle deformities. This was a retrospective study of 50 cases with an average follow-up of 24.2 months. The patient population consisted of 18 men and 30 women with an average age of 57.6 years. Twenty-six percent of the cases had concomitant bony realignment procedures, while 20% had prior history of major hindfoot corrective procedures. There were 19 cases with intraoperative malleolar fractures, 12 cases that exhibited some degree of malalignment, and 6 cases of syndesmotic nonunion, and 8 ankles required early component revision. Minor wound complications that resolved with local wound care occurred in 9 cases, while 1 patient had a major wound complication requiring flap coverage. Each of these complications, other than wound complications, decreased with the surgeon's experience. Our results also indicate that the performance of major realignment procedures at the same time of implant arthroplasty is not associated with an increased incidence of complications. The results of this study suggest that total ankle arthroplasty is associated with a learning curve. Perioperative complications may potentially decrease with surgeon experience.     

缺血预处理对心脏瓣膜置换手术围术期甲状腺激素代谢的影响及临床意义

目的 :了解缺血预处理对心脏瓣膜置换手术围术期甲状腺激素 (TH)代谢的影响及临床意义。方法 :选取 16例风湿性心脏病 (风心病 )瓣膜置换手术患者 ,随机均分为实验组 (IP组 )及对照组 (C组 ) ,IP组采取缺血预处理方案 ,对照组不采取预处理 ,其余同IP组。分别于术前、转流中 (最低温 )、再灌注后 5min ,停机、术后 2 ,2 4 ,4 8h采取血样 ,测定血清总三磺甲状腺原氨酸 (TT3 )、总四碘甲状腺原氨酸 (TT4)、游离三磺甲状腺原氨酸 (FT3 )、游离四碘甲状腺原氨酸 (FT4)、促甲状腺激素 (TSH)浓度 ,组内各时点与术前 ,两组之间各时点进行配对比较。结果 :TT3 和FT3 水平在转流最低温时降至最低点 ,术后 4 8h仍低于术前 ,但IP组术后 2 4～ 4 8h二者水平明显高于对照组 (均P <0 .0 5 ) ,两组T4,FT4水平术后 2 4h已恢复术至前水平 ,各时点间无明显差异 ;TSH水平术后 4 8h两组均低于术前 ;IP组无严重并发症发生 ,对照组有 2例发生低心排。结论 :风心病瓣膜置换手术围术期呈现低T3 综合征 ;缺血预处理可以减轻瓣膜置换手术围术期低T3 综合征的严重程度 ,有利于心功能的恢复     

人工关节置换充填骨水泥对血液动力学的影响

目的观察人工关节置换术中充填骨水泥对血液动力学的影响。方法40例ASAⅡ～Ⅲ级行人工关节置换术的患者，观察骨水泥充填后10min内血液动力学的变化。结果充填骨水泥后10min内患者血液动力学都有显著变化（P〈0．05），个别患者血压下降严重。需升压药支持。结论人工关节置换术中充填骨水泥可致血液动力学严重波动，应引起重视。     

Ross术后中远期主动脉瓣反流的危险因素分析

Objective To analyze the risk factors of the postoperative mid- and long-term aortic valvular regurgitation after ROSS procedure(pulmanary valve homograft transplantation). Methods Between March 1998 and July 2007,47 patients[25male, 22 female, mean age (13.31±5.79) years, ronge 1-34 years] with aortic valvular disease underwent the Ross procedure at our insti tution. There were 6 patients suffering fron rheumatic heart disease and 41 patients suffering from congenital heart disease. The aver age aortic blood flow velocity was (4.67±3.47) m/s, the average pressure gradient across aortic valve (88.26±58.06)mm Hg, LVEDD (45.53 ±10.78) mm, EF 0.69±0.08. All the patients were followed up in out-patient departement by ultrasonic cardio gram. Multiple logistic regression analysis was performed to find out the risk factors of the postive aortic valvular regurgitation. Results There was no poetoperative death in hospital. The mean follow-up periods was (36.15±22.1) months, rasnge from 12 to 110 months and none long-dated death. Compared with the data recorded in hospital, the diamenters of the aortic sinus and aortic annu lus enlarged significantly, respectively from (26.16±5.10) mm to (32.37±6.84) tam and from (19.41 ～3.98) mm to (23.45± 5.86) mm. The average flow velocity d the homograft (new aortic valve) was(1.39±0.48) m/s, graclient pressure (8.17+6.16) mm Hg. Mild aortic regurgitstion was present in 5 patients (10.6%), moderate aortic tegmgitafion in 2 pmieats (4.3%) and aevere aortic regurgitation in 1 petient (2.1%). The rate of free from regurgitation was 82.9%. Multiple logistic analyses identified the per esence of bicuspid aortic valve, enlargement of aortic annulus and age above 14 years as the risk factors for posterative aortic regurg itation. Conclusion The Ross procedure is a safe and effective procedure with good clinical results in mid-and long-term follow-up. However, the presence of bicuspid aortic valve, enlargement of aortic annulus and age above 14 years preoperatively were identified as the risk factors for postoperative aortic regurgitation.     

Combined aortic and mitral valve repair in active infective endocarditis

We describe a case of successful combined repair of the aortic and mitral valves for an indication of active infective endocarditis involving both valves. Mitral valve repair was achieved by vegetation debridement, fixation of the anterior mitral commissure, resection and suturing of the posterior mitral leaflet, and posterior annuloplasty with autologous pericardium. Aortic valve repair was achieved by vegetectomy and commissural plication. Postoperative clinical course was without signs of recurrent infection, and echocardiogram demonstrated mitral valve competence with trivial aortic regurgitation. We concluded that simultaneous valve repair is a viable option in the context of active endocarditis.     

二尖瓣成形术临床应用542例及随访

目的回顾性总结542例二尖瓣成形术病人的手术疗效和20年随访结果。方法1985年至2006年，542例二尖瓣病变的病人接受二尖瓣成形术，男306例，女236例。474例随访1-240个月，平均（41．03±40．40）个月，随访率90．8％。结果手术死亡20例（3．7％），出院时病人心功能均为Ⅰ级或Ⅱ级。随访死亡20例，再次手术23例；7年、10年和15年生存率分别为91％、88％和70％；7年和10年二次手术免除率分别为94％和86％。结论二尖瓣成形治疗二尖瓣病变，死亡率低，远期效果好。